If pain isn’t in our head, then where is it? In our June 23 issue, Laura Kolbe, a physician, clinical ethicist, and poet, reviews three new books on the historical, physical, and cultural aspects of pain. As a doctor, Kolbe is attuned to how pain shapes the relationships between doctors and patients and, on a larger scale, medical practice in America. She also grapples with the limitations of the language around pain. Even though expressions of pain so often fail to capture its essence, she argues, we must persist in attempting to construct a language around this disruptive malady.
Kolbe has written previously for the Review on the fiction of Giorgio Bassani and Silvina Ocampo. Her first book of poems, Little Pharma, was published last year. We e-mailed this week about principles of pain management, Wittgenstein, and the trap of bending pain into narrative.
Lauren Kane: What first made you interested in pain? Where does your work in medical ethics intersect with pain management?
Laura Kolbe: I like Haider Warraich’s line that doctors who have not experienced significant pain but who treat people in pain are “like chefs who have never tasted their own food.” I quote it approvingly in my piece, and I think there’s a good deal of truth in it, but of course it’s not wholly true. We’ve all experienced certain forms and degrees of pain. But more importantly, we are all enmeshed in the lives of others: I would venture that most health care workers in the US are close with at least one person in significant chronic pain, someone whose use of opioids or other substances has seriously altered their body’s fundamental pain tolerance and responses, or someone who has been through an experience of acute pain from a physical accident or illness. Chronic pain, too, is currently one of the most common reasons people in the US seek medical care.
So to be what I am—a doctor living and practicing in America today—is to inhabit a world etched by pain, where pain is a fairly regular consideration in navigating intimate and civic relationships, even apart from professional practice.
Many clinical ethicists and physicians working with people in pain would frame their dilemma as an inability to honor two competing values equally. On the one hand, there is the principle of doing no harm and offering a therapeutic plan only if the doctor believes it will benefit the patient. On the other hand is the principle of respecting a patient’s own mind, perceptions, experiences, and vision of what it would take to be well. Taken to its maladaptive extreme, the former principle (a fundamentalist commitment to believing the latest biomedical consensus) gets you to some awful places in medical history—for example, lumping all manner of diseases and mental states under the heading of women’s “hysteria,” or the historical and ongoing undertreatment of pain when reported by Black patients. And taken to its maladaptive extreme, the latter principle (a fundamentalist commitment to believing what others say and discrediting the evidence of one’s own senses and conscience) gets you pill mills and collaboration, either witting or unwitting, with unsavory aspects of the pharmaceutical industry.
In my practice I seek to have it both ways: to respect patients and my own mind enough to believe that we can meet in the open field of conversation with our mutual intuitions, experiences, and bodies of knowledge.
It would be “nonsensical,” you write in the piece, “to say that someone is in pain but not aware of it.” The same can be said of pain’s antithesis, pleasure. How would you qualify these feelings, which are just as much rooted in our physiology as our psychology? Should we think of them as emotions, like sadness and anger, or something different?
They’re not emotions, but they mingle with emotions. Nociception—a detection in the nervous system that some noxious stimulus has damaged or could damage tissue—is a complex feat of chemistry and electricity that is still incompletely understood. But its complexity is nothing compared to pain itself, which is nociception processed through the filters of an individual life history: the deep genetic and epigenetic history each person bears; the person’s hopes, fears, and anticipations; and how attentive or distracted that person happens to be at the moment pain strikes. The bare perception of a pleasurable physical stimulus is equally dwarfed by capital-P Pleasure, which, again, is in part due to present-tense stimulus but is richly inflected by stimuli past, present, future, and conditional.
You must write and read about pain in medical journals often. How do you approach the topic when addressing a popular readership, like in the books under review in your article, as opposed to the medical community?
In some ways, both the peer-reviewed literature and the more broadly accessible literature are subject to a similar risk, which is the desire for positive and narratable findings.There’s substantial data showing that study results that claim that a particular intervention yields a significantly different outcome compared to whatever the control group or the current baseline is are more likely to be accepted for publication in scientific and medical journals. Even in these rarefied realms that we tend to think are objective, scientists, physicians, and editors are still, to some extent, just people who want to be told a satisfying story. And satisfying stories often require change, revelation, epiphany. If medical and scientific journals didn’t have this bias, more articles would say, in essence, we tried this new intervention and it didn’t work any more than what we were doing before. We’re still deep in the woods.
In works for a popular readership, of course, this is even truer. We gravitate toward the narrative arc that says: I didn’t understand what my pain is or means, and now maybe I do. And in prose for the nonspecialist audience, many writers understandably resist losing momentum by second-guessing, by adding caveats, by making counterarguments. I think the best, most lasting examples of great nonfiction about the body, medicine, and science find ways to turn those swerves and pauses into integral parts of their prosody, of the characteristic melody of one mind humming.
I’ve noticed Elaine Scarry’s The Body in Pain referenced often in my reading lately. Is there something about that book that is especially resonant right now?
To me the book’s abiding curiosity is about the nature of experiences so overwhelming to the human mind that they can shut down the ability to be, do, and think other things. Pain is the cardinal example of this. But other strong physical sensations and emotions can certainly approach that extreme. Mental and bodily states that preclude multiplicity of self—that only allow you to be “she who is experiencing pain” (or hunger, or nausea, or rage, or depression, or what have you)—are the black hole of social and political life, which in its ideal forms permits you the space to think and feel, and to listen to and interact with a variety of human speakers and agents. Scarry’s argument is that to induce that kind of absolutely narrowed state in another human being—through physical torture, for example—is the worst thing you could do, the most antihuman act.
Extrapolating a bit, I think those mono-states are also the antithesis of artistic, scholarly, and literary life. When I write a poem, or when someone writes fiction or even engages in, say, historical research, there needs to be enough cognitive room for the mind to consider the range of possible beliefs and points of view, to toss up and abandon and mess around with hypotheses, voices, poses. Scarry’s book, by providing an atlas of those states of mind that inhibit thought, play, and creation, is sort of like a photonegative of the necessary conditions for a cognitive world—and a social, interpersonal world—in which politics, participation, art-making, and knowledge production can happen.
You’ve also reviewed fiction for The New York Review, and you end your essay with the suggestion that art gets closer to expressions of pain than scientific approaches do. Can you say more about that? Why do you think something like pain could be more successfully expressed in fiction or performance?
Works of art and literature can, if they choose, eschew exposition and information delivery. They therefore have an easier time than does more utilitarian nonfiction at slipping the obligation to provide a smoothly reasoned narrative. A work of art could, for example, mimic the stuckness of being ill or in pain, or the way pain makes our emotions or thought processes more labile or friable, or pain’s recursions and repetitions. Those kinds of stylistic options are less available to the kind of prose that’s primarily intended to transmit facts, and they are certainly unavailable to the reporting of scientific study results – at least under the current genre conventions that govern the peer-reviewed professional article.
Your review deals largely with the “yawning gap” in communication between someone who is in pain and someone who isn’t—and you argue that the person in pain does in fact have a kind of “private language,” against Wittgenstein’s belief that such a thing cannot exist. What, to your mind, is the best method, or a few of the best methods, to try and bridge that impossible gap?
Far be it from me to argue with Wittgenstein! (I should also state the obvious here, which is that I am absolutely not a philosopher.) My point was that I do sympathize with how pain can seem to trap one in a “private language,” where communication between someone who’s in pain and someone who’s not can seem to rupture. Because the words that one person uses can’t get across, no proper listening or replying can happen. And the person in pain could feel like the only way forward was to invent a new term or terms that stood completely outside the language system that pain-free people use (though Wittgenstein is saying in part that even neologisms or new ways of speaking slot in to the inherently joint and joining venture of language).
I can commiserate with the feeling that language could break or has broken down completely—I can understand or imagine, I think, linguistic despair. But as a writer and as a doctor, my whole life’s work is staked on the belief that this despair is wrongheaded. We may do badly (repeatedly, chronically, even disastrously) at the work of trying to speak to and listen to one another, of trying to say what we mean and to understand what others mean, but the fundamental enterprise—of reaching each other, of mind touching mind—is essentially sound (not to mention beautiful and fun!), and can be improved through diligence and creative spark. If I didn’t believe that I’d have to quit both my jobs.